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IN THIS ISSUE

Vol. 7 No. 2March/April 2005

IIIIImplant Nmplant Nmplant Nmplant Nmplant Newewewewews & Vs & Vs & Vs & Vs & Viewiewiewiewiewsssss “Keeping y“Keeping y“Keeping y“Keeping y“Keeping you up-to-ou up-to-ou up-to-ou up-to-ou up-to-date on implant dentisdate on implant dentisdate on implant dentisdate on implant dentisdate on implant dentistry”try”try”try”try”

Immediate Placement of Implants

after Extraction: A Literature Review

Dr. Bertrand Bonnick, Dr. Andrew Kelly,Dr. Richard Nguyen, Dr. Alex Resnanskyand Dr. Jean Woods

Page 2

Tidbits

Page 3

Are Dental Implants a Predictable

Alternative for Organ Transplant

Recipients and HIV Patients?

Cheryl Thomas, RDH, Lynne Slim, RDH,and Lisa Wadsworth, RDH

Page 6

Key Factors in Immediate Loading

Dental Implants

Dr. George Mantikas

continued on p. 8

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Immediate Placement of Implants

after Extraction: A Literature Reviewby Drs. Bertrand Bonnick, Andrew Kelly, Richard Nguyen, Alex Resnansky, Jean Woods

There are mixed opinions on the success of immediate implant placementat the time of extraction. Immediate placement of implants brings into the suc-cess equation many variables not found in routine implant placement. Issues suchas bone density, bone preservation, bone grafting, the presence of infection, tra-jectory of placement, types of implants, use of membranes are some of the fac-tors considered. Various techniques, complications, and retrospective studies wereused to examine the efficacy of immediate implant placement. Immediate place-ment shortens the time that it takes before a patient can have a restored dentition;it also lessens the amount of surgical exposure for the patient. The practitionershould be careful because the choice of cases and technique influences the over-all success rate of the implant.

Fig. 1 Fig. 2Trad i t iona limplant placement andpredictable outcomesfirst came to us throughthe work of Adell,Lekholm, Rockler, andBranemark 1. In 1988-1992 a study done byMensdorff-Pouilly et al.comprising 190 imme-diate implantation (93primary immediate im-plantations and 97 sec-ondary immediate im-plantations performed 6to 8 weeks postextraction) showed that the group of primary immediate implants showed a tendencytowards deeper pocket formation and an increased frequency of membrane dehiscences that may bedue to the poorer quality of the soft tissue covering 2.

In 1993 Barzilay presented a paper on Immediate Implants: Their Current Status. He refersto the change of prosthodontic treatment in North America after the introduction of “osseointegrationtechnology” at the 1982 Toronto Conference. In theory the concept provided many advantages includ-ing fewer surgical sessions, reduced overall costs, and preservation of alveolar bone height. He refers tothe poor success rates with soft tissue noted at the interface in earlier studies; however he hinted thatshort-term research using animals and humans has shown that immediate implants are comparable toimplants placed using the conventional technique. He concluded that long-term studies were needed 3.

As knowledge of immediate implant surgery and tissue management increased reportedsuccess was more encouraging for this modality. Covani et al. in his 2004 study was able to achieve a 4year cumulative success rate of 97% and moreover, no statistically significant differences were observedin terms of clinical attachment level between those implants treated with GBR and those without

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Internet ResourcesBroken screws in implants and/or abutments may lead to implant failure. Zimmer has

some good information on removing broken screws at http://www.zimmerdental.com/

lib_techTipBrokeScr.asp . They also sell a Thread Retrieval Kit that can be used to removebroken screws. Nobel Biocare has a well-done instructive video on live “all-on-4” implant surgeryby Dr. Paulo Maló of Lisbon, Portugal at http://www.nobelbiocare.com/global/en/

ClinicalProcedures/EdentulousJaws/default. There is a second video on delivering the bridge.Book

Quintessence Publishing [1.800.621.0387] is promoting their new book, Bone Biol-

ogy, Harvesting, and Grafting For Dental Implants: Rationale and Clinical Applications

edited by Arun K Garg and retailing for $158. Many patients who are otherwise ideal candidatesfor implant therapy lack sufficient alveolar bone to support dental implants. This book presentsall facets of bone augmentation in preparation for implant placement, including techniques forharvesting bone from the ramus, the anterior mandible, and the tibia; the various types of bone-grafting materials and their indications; step-by-step procedures for grafting the maxillary sinusand anterior alveolar ridge and for subnasal elevation and augmentation; and guidelines for theuse of adjuncts such as platelet-rich plasma to enhance healing and predictability. Practitioners ofimplant dentistry at all levels will learn much from this book.

Dr. Garg states in his preface, “For the past 10 years, many of the questions raisedduring my hands-on cadaver, live-surgery, and lecture programs have pertained to bone biology,graft materials, membranes, bone harvesting, or bone grafting. While it seems that most practitio-ners today have been adequately trained in the technical aspects of placing implants, I find thatmany lack knowledge of the basic biologic processes that allow us to harvest bone from one areaof the mouth and graft it in another. Since the format of a short lecture or even a one-day coursedoes not allow me to delve very far beyond the step-by-step procedures associated with harvestingand grafting bone, I conceived the idea of writing a book that would explain not only how toperform these and other procedures, but also why we do them one way and not another and whatmakes the procedures work. Above all, my aim in writing this book was to arm the clinician witha sufficient understanding of bone and bone grafting to be able to make decisions that will benefitindividual patients, without overwhelming him or her with information that is not directlyrelevant to that purpose...It is truly remarkable to consider how much implant dentistry hasevolved over the past two decades. Today we are able to restore function in patients with as littleas 1 mm of crestal bone height, providing they have adequate ridge width to accommodate theintended implant. This has significantly expanded the number of patients who qualify as candi-dates for implant therapy, but the clinician must be knowledgeable about the needs of thesepatients and how to meet them successfully. This book is designed to bridge that gap inknowledge...This book is intended primarily for the advanced clinician in periodontics and oraland maxillofacial surgery who desires a comprehensive and clinically relevant review of both thebackground science and clinical applications of bone for dental implants. The book will also beuseful for graduate students in oral and maxillofacial surgery, periodontics, and hospital dentistryresidency training programs and for the academic surgeon with an interest in this importantsubject.”

Consultation ToolRecently we ran across a company, Consult-Pro [1-800-519-6569] out of Toronto,

Canada that sells a CD with comprehensive education modules used for case presentation andpatient consultations. There is an excellent implant section with high quality graphics that makethe concept of implant treatment easy to understand. Its use should lead to higher patientacceptance of implant therpy. Dr. Craig Misch and Dr. Sam Strong have given very positivetestimonials on its benefits. You may visit them online at www.consult-pro.com.

Tibits

TibitsTibits


continued on p. 4

Are Dental Implants a Predictable Alternative for

Organ Transplant Recipients and HIV Patients?

by Cheryl Thomas, RDH, Lynne Slim, RDH, BSDH, MSDH and Lisa Wadsworth, RDH

As the overall health of the American population has increased, so has life expectancy. Americans are livinglonger than at any other point in our history and people who survive to the age of 65 can expect to live an averageof 18 additional years. This year, the oldest baby boomers have turned 55 and this is the official age in which manyare referred to as “seniors”. These new “seniors” are entering the second half of their lives with a youthful andvibrant self-image. Boomers are entering into retirement and into active retirement communities with far-reachingagendas. Many of these “Zoomers” are financially established, healthy and very demanding.

For the young and old, dental implants will continue to be a superior and predictable alternative to a fixed or removable prosthesis. Asthe “Zoomers” age, medical challenges will emerge that will affect dental treatment planning for this particular population group. Those who aremedically compromised present with complex medical histories that demand physician consultation and collaboration.

Organ donation and HIV status are two medical conditions that are rarely discussed in the implant literature and by practicing implantologists.The purpose of this article is to review what is known about the two aforementioned medical conditions and their impact on implant placementand retention.

Are organ transplant recipients suitable candidates for dental implants?Organ transplants are one of the modern day miracles of medicine. Demand for organ transplants will undoubtedly increase due to the

rapid rise in the aging ‘Zoomer’ population along with a steady increase in the incidence of diabetes and Hepatitis C. There are currently 87,000+people on the organ waiting list according to UNOS (United Network for Organ Sharing)1 Pam Silvestri, Director of The Southwest TransplantAlliance, states: “In the last 10 years the list has grown by more than 300 percent. By 2010 estimates say 1 in 10 people will need an organ or tissuetransplant.”2 The Southwest Transplant Alliance is an agency that works directly with UNOS on a regional basis representing organ transplantationin Texas and Oklahoma.

InfectionOrgan transplant recipients are susceptible to infection due to immunosuppressive medications. Cyclosporine, Cellcept, Tacrolimus,

Rapimune, and Prednisone are still the model drugs for immunosuppressive therapy. These medications are necessary to prevent graft rejection;however, they leave patients susceptible to life-threatening sepsis. Will susceptibility to infection prove to be an obstacle for dental implants?Medically stable transplant recipients recover well from various surgeries. Hip replacement surgery was addressed by Lo, NN et al and this surgicalprocedure was deemed a success in renal transplant recipients.3 Keep in mind, however, that in hip replacement surgery “THR is the treatment ofchoice for patients with painful osteonecrosis of the hip after renal transplant, but has higher rates of both early and late complications. Surgeryshould be performed in close association with a renal transplant unit.”4 To avoid the complication of infection for any surgical procedure, theimplant team should work closely with the renal transplant unit and will need to recognize and treat any sign of infection early. Antibiotics The American Academy of Orthopaedic Surgeons (AAOS) recommends antibiotic prophylaxis for surgical procedures performed ondrug-induced immunosuppressed patients in its advisory statement “Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements.”5

(The document in its entirety may be found at: http://www.aaos.org/wordhtml/papers/advistmt/1014.htm). The transplant community isdivided on the topic of antibiotic prophylaxis for invasive dental procedures. The implant team should thoroughly evaluate the risk of infectionand determine if antibiotic therapy is indicated for prevention of host infection.

Patient Selection

In selecting patients for dental implants, systemic diseases must be taken into consideration. For example, it is well recognized that apoorly managed diabetic patient would not warrant a favorable dental implant prognosis. Pre-operative blood work, CT scans, bone density scans,and medical evaluations of the organ transplant recipient by the patient’s primary care physician are recommended. The primary care physician anddental implant team must work hand in hand to evaluate the medical stability of the candidate.

Renal TransplantRenal transplants are the most commonly performed transplants. When determining a medically stable transplant recipient, one must

evaluate the whole picture and not only the organ involved because these patients frequently present with multiple organ involvement. The idealcandidate for a dental implant is one that is monitored routinely by an appropriate health care provider. The nephrotoxicity of immunosuppres-sive medications may subject hepatic and cardiac transplant recipients to end stage renal disease and possibly renal transplantation. The mostcommon causes of end stage renal disease are diabetes, hypertension, and glomerulo diseases. The etiology of the patient’s renal disease shouldbe well controlled before elective surgery.


fig. 6

continued from p .3

Are Dental Implants a Predictable Alternative for

Organ Transplant Recipients and HIV Patients?

TestingCreatinine and bilirubin are routine blood tests that establish renal and hepatic function respectively. “Creatinine (kree-AT-uh-nin) is a

waste product that comes from the normal wear and tear on muscles of the body. Creatinine levels in the blood can vary depending on age, raceand body size. A creatinine level of greater than 1.2 for women and greater than 1.4 for men may be an early sign that the kidneys are not workingproperly. The level of creatinine in the blood rises, if kidney disease progresses.”6 However, a renal transplant recipient with level of 1.6 may proveto be an ideal candidate. This level may be the patient’s new “norm.” Body mass, weight, and fluid retention may elevate creatinine levels and notbe a true indication of renal function. Protein or blood in the urine is an indication of failing renal function. Twenty-four hour urine analysis,blood urea nitrogen levels, and Glowfils are an intricate piece of the puzzle and should be evaluated. Among the important substances the kidneyshelp to control are sodium, potassium, chloride, bicarbonate HCO3- (measured indirectly as CO2), pH, calcium, phosphate, and magnesium andany abnormality in these levels could be indicative of an underlying renal problem.

Liver TransplantCirrhosis of the liver due to hepatitis and alcoholism are the most common cause of liver failure. Liver transplantation is the second

most commonly performed transplant. Bilirubin is produced in bone marrow cells and in the liver as the end product of red-blood-cell,hemoglobin breakdown. The amount of bilirubin manufactured relates directly to the quantity of blood cells destroyed. Normal values of directbilirubin are 0 to 0.3 mg/dl and for total bilirubin: 0.3 to 1.9 mg/dl. Most important, the patient’s red and white blood cells should be withinnormal limits. The liver converts nutrients derived from food into essential blood components, stores vitamins and minerals, regulates bloodclotting, produces proteins and enzymes, maintains hormone balances, and metabolizes and detoxifies substances that would otherwise beharmful to the body. The liver is an integral part of the immune system in fighting infection and removes bacteria from the blood. Any infectionis a contraindication to surgical procedures in organ transplant recipients.

Vital SignsRegardless of the organ transplanted, stable vital signs are necessary as they would be for any implant candidate. Side effects of

medications should be researched. Prednisone is a common medication taken by organ transplant recipients. The side effects of prednisoneinclude: delayed wound healing, susceptibility to infection, osteoporosis, osteonecrosis, and the possibility of adrenal crisis with surgical proce-dures. Prolonged therapy with prednisone causes the adrenal glands to atrophy and stop producing cortisol; therefore, a medical consultation iswarranted to determine if a temporary elevation of prednisone is indicated for surgical procedures.

Though organ transplants have been successfully performed for over 50 years, fewstudies have addressed the possibility of dental implants for organ transplant recipients. Inone particular study that included a ten-year period of tracking a liver transplant recipient, thecause of liver disease resulted from cirrhosis and hepatocellular carcinoma. The patient’s lasttwo teeth were removed prior to transplantation. The patient received a liver transplant in1992 at age 61. Six months after transplant, two implants (solid screw, diameter: 3.3mm,length: 12.0mm) were placed in the interforaminal region [fig. 1]. Osseointegration wasachieved and an overdenture was fabricated. In 2004, a ten-year follow-up showed stableliver function. In addition, the dental implants were deemed a success [fig. 2]. “This casereport suggests that immunocompromised patients can be successfully rehabilitated withdental implants.”7 Dr. Heckman, the principal author of the aforementioned research paper,was asked if renal transplant recipients would also prove to be good dental implant candi-dates. Dr. Heckman responded as follows: “From my experience, a renal transplant recipientwith stable bone density can be treated with dental implants.”8

Implant Studies

Fig. 1

Fig. 2

It is estimated that 10% of transplant recipients treated with cyclosporine developgingival overgrowth. “Its severity reflects the interaction of effective dental hygiene,cyclosporine dose, and concomitant administration of calcium antagonists (particularlydihydropyridines). This complication does not seem to occur with use of tacrolimus, andcomplete resolution of gingival hyperplasia has been noted with the conversion fromcyclosporine-based therapy.”9 Furthermore, research has shown that Human LeukocyteAntigen (HLA), used in organ matching criteria, may explain why some patients have ahigher incidence of gingival hyperplasia. By testing lymphocytes, the transplant team is ableto determine which HLA antigens the patient has as a part of their genetic makeup todetermine which tissues would have the “best genetic match.”

Cyclosporine

Radiographs courtesy of Dr. Siegfried

Heckmann and the Journal of Periodontol-

ogy.


References on p. 11

Today, 118 different known HLA antigens have been discovered. Though some transplants are performed without any HLA matches,a majority of the transplant community believes that the better the antigen match, the less likelihood of rejection. The success of dental implantsrelies upon proper placement and technique. If an implant is placed correctly, gingival overgrowth should not be a concern given the smoothsurfaces of dental implant structures; however, if chronic gingival overgrowth manifests, changing immunosuppression therapy from cyclosporineto tacrolimus is a viable option.

Side Effects of Anti-Rejection MedicationsCyclosporine is notorious for causing gingival overgrowth; however, the list of oral side effects also includes gingival bleeding, salivary

gland enlargement, tongue disorders, taste perversion, xerostomia, candidiasis, hyperkalemia, abscess, bacterial and viral infection. Carcinoma,bone fracture, and secondary diabetes mellitus are also side effects that could have a dental impact. Cellcept oral side effects include gingivitis,gingival overgrowth, xerostomia, Cushing syndrome, parathyroid disorder (which may be indicative of renal osteodystrophy), infection, mouthulcerations, stomatitis, hypercalcemia, osteoporosis, coagulation disorder, and some cases of infectious endocarditis have been reported.

Secondary diabetes mellitus is also observed as a side effect of anti-rejection medications. Rapimune oral side effects consist of gingivitis,gingival overgrowth, parathesia, mouth ulcers, stomatitis, abnormal healing. Hypocalcemia, Cushing syndrome, diabetes mellitus, bone necrosis,osteoporosis, sepsis, and viral infections may also develop. Comparatively, Tacrolimus has relatively few listed oral side effects (taste perversionand tooth disorder). All of these medications are nephrotoxic. Hypertension, hypotension, cardiac disorders, hematolgic disorders, convulsions,and susceptibility to infection are also common side effects of all the aforementioned medications. Experimental anti-rejection medications areintroduced daily. Many transplant recipients participate in drug research and often the side effects of these medications are unknown.

Bone DiseaseBone diseases pose the biggest obstacle for implantologists. For instance, end stage renal disease and dialysis commonly resul t in

degenerative bone disease due to secondary hyperparathyroidism. “Bone loss is rapid after transplantation, most likely as a result of corticosteroidtherapy. The rate of bone loss is greatest in the first 6 months, after which it slows somewhat.”10 “Although the majority of bone loss fromprednisone occurs during the first 6 months of therapy, it is known that people who are on more than 5 mg of prednisone long term will continueto be at risk for bone loss.”11 “Patients taking long-term prednisone often receive supplements of calcium and vitamin D to counteract the effectson bones. Calcium and vitamin D probably are not enough, however, and treatment with bisphosphonates such as alendronate (Fosamax) andrisedronate (Actonel) may be necessary. Calcitonin (Miacalcin) is also an effective supplement. The development of osteoporosis and the need fortreatment can be monitored using bone density scans.”12 The loss of bone density experienced by a person taking corticosteroids varies on anumber of factors. For example, bone loss appears to be greatest when corticosteroids are taken orally than by other means and when they are usedin higher doses and over longer periods of time.

Secondary Osteoporosis Secondary osteoporosis is also seen in patients taking phenytoin (Dilantin®), barbiturates, methotrexate (Rheumatrex®, Immunex®,

Folex PFS®), cyclosporine (Sandimmune®, Neoral®), Tacrolimus (Prograft®), luteinizing hormone-releasing hormone agonists (Lupron®,Zoladex®), heparin (Calciparine®, Liquaemin®), and cholestyramine (Questran®) and colestipol (Colestid®). Post-menopausal women andmen with low testosterone levels are at high risk for osteoporosis. Patients with diabetes prove to be at high risk for low-turnover bone disease.“Plain radiographics are insensitive for the diagnosis of osteopenia, and the current standard of measurement is BMD, performed by dual X-rayabsorptiometry (DXA). Osteoporosis has been categorized into three subtypes: - Type I is due to decreased estrogen exposure in post-meno-pausal woman and decreased testosterone production in males2, 3; - Type II is the generalized bone loss that occurs as a result of aging; and - TypeIII, or secondary osteoporosis, is due to the administration of drugs such as corticosteroids, liver disease, immobilization, or hyperthyroidism.”13

Magnetic resonance imaging is a sensitive diagnostic method allowing detection of osteonecrosis at a very early stage and would be a useful toolin evaluating bone integrity. Careful evaluation of the integrity of the bone and the location of the implant site must be taken into consideration.A peri-implant infection may pose a hazard to the patient’s general health and to the transplanted organ. A patient may become septic to infectionor the infection may activate an immune response that leads to a rejection episode.

Is there a cure for bone disease in sight? Researchers from the Renal Divisions, Departments of Medicine and Pediatrics, WashingtonUniversity School of Medicine, St. Louis, MO, injected mice that had been subjected to electrocautery of the right kidney followed by nephrectomyof the left were injected with the protein, bone morphogenetic protein-7 (BMP-7). The study was controlled for hyperparathyroidism. Theresearchers discovered that the mouse group that received BMP-7 had nearly normal bone structure while the control group did not. Accordingto one of the clinicians, Keith A. Hruska, MD, BMP-7 may “totally eliminate the development of skeletal deformity.” Hruska tol d ScienCentralNews that he also plans to study the effect of BMP-7 on heart disease in kidney failure and that the protein may even eventually reverse CKD itself.According to a report in the Journal of the American Society of Nephrology, “ABD produced in mice with CKD in the absence of hyperparathroidismwas successfully reversed with a bone anabolic, BMP-7, associated with a reduction in plasma phosphorus.”14

After organ transplantation, patients need to avoid habits that prove detrimental to their health and oral health professionals need tooffer them an opportunity for improved oral health. Patients who continue to smoke or imbibe alcohol are not good candidates for dentalimplants. Smokers demonstrate poor wound healing and a predisposition to periodontal diseases. “In alcoholics these diseases appear to becaused primarily by bad oral hygiene and poor dental care.”15

Because infections may be masked in immunosuppressed patients, frequent continuing care appointments including examinationsshould be emphasized. Patients should be instructed to identify the signs of implant failure or infection. These signs should be stressed, andpatients should be urged to seek care immediately should any signs of infection appear.


Table Clinics

This table clinic was presented in November 2004 at the American Academy of

Implant Dentistry’s Annual Meeting held in New York, NY.

Key Factors in Immediately Loading Dental Implantsby Dr. George Mantikas

Immediate Provisional ImplantThe placement and temporization of a dental implant at the time ofsurgery in a •Previous Edentulous Area •At the Time of Extraction.

Treatment Options to Replace a Single ToothBasic prosthetic options presented to the patient: 1.Free StandingImplant 2. Fixed Bridge 3. Removable Partial Denture

Vincent Kokich, DDS, MSD•Reported the Following by Early loading dental implants1. The crestal bone is maintained. The reports indicate that by delaying the load on implantsa significant amount of crestal bone is lost.2.In periodontally infected areas, the immediate placement and loading enhance the mainte-nance of bone and does not affect the success of the implant.3.Osseointegration is more favorable with immediate placement of implant following anextraction.

Implant ConsiderationsThese are basic factors affecting the success of any oral surgery: •Patient’s Health •Smoker•Bruxism •Bone Level •Bone Width •Condition of Surrounding Teeth •Missing Teeth onArch •Patient’s Hygiene.

Advantages of Provisional Load Implant•Esthetic considerations •Ridge Preservation •Papilla Preservation •Single Phase Healing•Single Surgery •Ease of Temporization •Cost Consideration •Time Consideration.

Immediate Implant Cautions•Quality of Bone •Surgical Procedure •Possible Allergy •Poor Dentition.

PreparationThe most important aspect is the preparation prior to the surgical procedure. You can notskip steps! In order to have predictable successful results, certain steps must be taken. Cut-ting corners reduces success rate.1.Impressions for: a.Diagnostic wax-up b. Surgical template c.Temporary fabrication2. Radiographs for: a. Identify Landmarks b. Determine bone height c. Determine bonewidth.

Treatment Sequence and Appointments1. Diagnostic models and wax-up. 2. Extraction and placement of implant, final impres-sion and temporary placement. 3. Suture removal 7-10 days later. 4. One-month post-op

radiograph. 5. Three-four month radiograph and try in (placement) of final restoration.

Case History # 1•32 year old Male •Negative Health History •Failing post and core and crown on toothnumber 5 •Surrounding dentition unremarkable [figs. 1-12].

Case History #2•51 year-old female •Negative health history •History of failed RCT/P&C/Crown •Tooth

#28 [figs. 13- 16].

Fig. 1 – Pre-op Panorex.

Fig. 3 – Radiograph of implant placement.

Fig. 4 – Tooth removed; Sulzer

4.7 X 13mm implant installed

wiht transfer post in place.

Fig. 2 - Pre-op periapical of tooth #5 reveals

base of the sinus and crestal bone height.

Continued on p. 7


Fig. 15

Fig. 5 - Temporary stock abutment placed.

A permanent abutment can also be used.

Fig. 6 - The abutment is shaped and pre-

pared for the provisional restoration.

Fig. 7 - The provisional crown is relined

and placed; a suture holds the athe

releaseing flap necessary to extract the

tooth.

Fig. 8 - Four week follow-up. Notice the

healthy tissue.

Fig. 9 - the try-in of the permanent abut-

ment and Procera coping. A radiograph

is necessary to confirm the fit. Fig. 10 - Abutment & coping in place.

Fig. 11 - Final periapical.Fig. 12 - Final Procera crown in place. Fig. 13 - Tooth # 28 fractured at the gum

line.

Fig. 14 - Pre-op radiograph. Fig. 15 - Implant and temporary abutment

in place. Fig. 16 - Temporary crown in place.Summary

Immediately loading of dental implants is agood alternative treatment involving simplesurgery. When you have good preparation,the results are very predictable.

George Mantikas, DMD maintains a private practice in East Hampton, Connecticut withan emphasis on comprehensive, family dentistry. He is a member of the American Acad-emy of Implant Dentistry. He can be reached at [email protected] or 1-860-267-7768.

fig. 9


GBR. Covani adhered to strict guidelines that included patientswere placed on a strict oral hygiene, the use of GBR procedureswere reduced, implant surfaces were acid etched/sandblasted,and all prosthetic restorations were single crowns 4.

Current implant systems with reliable internal con-nection ensure predictable success of restorations if guidelinesare followed. Castellon et al. summarized guidelines for singletooth immediate provisionalization so we can go one step fur-ther after immediate placement of the implant. Hard tissue,soft tissue, and space available were the criteria used. Bone heightgreater than 10mm and width buccal-lingually of 2mm, softtissue with papilla and keratinized gingival and interocclusalspace of 1.5mm to 2mm mesiodistal 2mm buccolingual and7mm apicocoronal were the best criteria 5 [figs. 1-2].Garber and Salama and Salama documented the technique for

Immediate Placement of Implants after Extraction: A Literature Reviewcontinued from p. 1

fig. 3 fig. 4

fig. 5

fig. 6

immediate implant placement in a site where external resorption was taking place [figs 3-4].Use of peritomes is contraindicated because osteoclastic activity is indiscriminate in its de-struction of the periodontal ligament space and lamina dura of the bone. The coronal partof the tooth is removed and osteotomy is performed through the remaining tooth structureinto underlying bone. Tooth remnants can then be removed and socket cleared of any leftover debris. Immediate temporization can be accomplished so the patient does not have towear a removable appliance in the esthetic zone. The temporary is kept out of occlusion toallow time for bone fill and osteointegration 6.

Dehiscence Coverage, Preservation

of Esthetics and Histologic StudiesWilson carried out histological analysis of immediately placed implants in 1998. 15

ITI TPS implants were placed, 6 in the maxilla and 9 in the mandible. All implants wereosseointegrated at the light microscopic level with varying percentage of direct bone-implant contact.This study provides histological evidence that immediately placed implants become osseointegrated 7.

In 2000 Nemcovsky discussed the clinical coverage of dehiscence defects in immediate implantplacement. 61 implants were placed in 61 healthy patients with primary tissue closure. The use of barriermembrane was not mandatory provided the implant was placed within a boney envelope, even if thatenvelope had partially missing bone. This study showed short-term successful results with bone graftand soft tissue coverage 8.

Bone Regeneration, Horizontal Fractures

Tooth Fractures, Placement Without AugmentationGher et al. studied the grafting and guided bone regeneration for immediate dental implants

in humans. The study evaluated bone regeneration and osseointegration of hydroxyapatite (HA) andtitanium plasma sprayed (TPS) implants place in sockets immediately after extraction in 36 adults witha mean age of 55.2 years. This study showed no significant difference in the osseointegration ofimplants whether HA or TPS implants were used. Implants grafted with demineralized freeze-driedbone allograft (DFDBA) along with a barrier material showed a +1.32 mm in crestal bone apposition atthe apical socket crest (ASC) than implants without grafting and barrier material, which showed a -0.11mm crestal resorption. The barrier material became clinically exposed in 24 of the 36 patients during initial post-surgical healing [fig. 5]. Sites thatretained the barrier material uncontaminated for the full 6 months had significantly greater bone apposition (+1.92 mm) at the ASC versus siteswhere the material required early removal (-0.21mm). There was no statistically significant difference in bone changes between the maxillary andmandibular arches. While the study group of 36 humans can be considered small the viability of immediate implant placement is encouragedbecause all 44 implants were osseointegrated at the six-month re-entry surgery 9.

Krauser et al. gave a case study for immediate implantation after extraction of a horizontally fractured maxillary lateral incisor. Thiscase is one in which fractured tooth #7 [fig. 6] needs to be extracted because of a horizontal fracture but the abutment teeth #6 and #8 do notrequire restoration. A full thickness flap is elevated preserving the interproximal papillae. Both sections of the tooth are removed with as littletrauma as possible. Socket debridement is performed with a #8 surgical bur and hand curettes. Place as large an implant as possible so it issnug and stable [fig. 7].

continued on p. 9


continued from p. 8

Densely pack graft material and cover it with a membrane, then cover with an occlusive barrier.After one month insert a transitional prosthesis [figs. 8-9]. This is a disadvantage for this techniquebecause the tooth loss is in an esthetic area and it would be hard to convince the patient to go one monthwithout a prosthesis. The authors warn that if the site is angled or the trajectory is off close and allowthe site to heal, then re-enter at another date. Another disadvantage of immediate insertion is theuncertainty of not knowing your outcome earlier in the surgery 10.

Cohen and Shenoy gave a similar case report involving a maxillary central incisor with similarsuccess yet they had immediate use of a provisional maxillary removable partial denture. They obtainedprimary coverage by sliding the full-thickness buccal mucogingival flap to the palatal flap without the useof grafting materials 11.

Becker et al. did an extensive study with 134 implants in 81 patients without augmentation orbarrier membrane. Forty-seven implants were followed over 4 to 5 years with a 93.3% success rate. Thisindicates that implants placed at the time of extraction without augmentation or grafting have excellentlong-term cumulative success rates 12.

fig. 7

fig. 8

fig. 9

Cosci and Cosci reported on 423 hydroxyapatite coated implants over 7 years (1989-1995). During the one year follow-up one implant was lost, and an additional implant failedduring the 7 year follow-up, with a final success rate of 99.53% 13.

In the early 1990’s Mason discusses his technique of immediate placement usingHA coated implants. He found that at the uncovering stage he would find bone growingover the implant. One the other hand Wallace prefers to use titanium implants because oftheir long-term success record and less possibility of periodontal problems due to HAdegradation 14.

Werbitt and Goldberg demonstrate with several cases that an intact extraction site isnot necessary for successful integration of a titanium fixture. Guided tissue regeneration andbone grafting can be used successfully in compromised sites 15.

Parel and Triplett described immediate placement of fixtures beneath the apices ofextracted teeth in the anterior mandible. This procedure was described as a radical departurefrom conventional mandibular protocol 16.Krump and Barnett compared results of placing endosseous implants into the anterior mandible atthe time of extractions with appropriate radical alveolectomies versus a control group 17. The success ofthe immediate group was 92.7% while the control group was 98.1%.

Landsberg describes a novel approach called the “socket seal surgery.” A 3 to 4mm thick softtissue graft that contains part of submucosa is obtained from the palate, the implant is placed in thesocket and the soft tissue sutured around the socket. A space screw can also be used when the implanthead is almost level with the labial crestal bone 18.

In 1995 Evian and Cutler present cases where a failed screw type pure titanium implants werereplaced immediately with a HA coated Ti-6Al-4V implants. This negated the common protocol at thetime where the failing implant was extracted, socket curetted and a one year healing period was ob-served. Success was enhanced when the sockets were prepared to remove grooves and soft tissue, thereplacement implant was larger in diameter than the original implant, and sufficient available bone remained for the procedure 19.

Enhancing Placement, Alveoloplasty and Resorbable MembranesIn 1991 Tolman and Keller reported their results from immediate placement of 301 implants in 61 patients over a six-year period. They

concluded that placement of implants were contraindicated in the presence of acute periodontal or periapical infections. However if these areas canbe eliminated with alveoloplasty, drilling, or tapping procedures then success can be expected. All 301 implants were osseointegrated andprosthetically loaded 20.

Delayed Immediate, Posterior Maxilla, and Retrospective AnalysesGrunder et al report compared the Immediate Placement and Delayed-Immediate placement over a 3-year loading period. It was found

that there was no difference in survival rate between Immediate and Delayed-immediate placements. The success rate was 92.4% for the 264 unitsplaced. There was some clinical correlation of higher failure rate when periodontitis was the reason for tooth loss 21.

Rosenquist and Grenthe studied the survival rate of Immediate Placed implants into extraction sockets. Of the 109 nobelpharmaimplants placed there was a 93.6% survival rate, 92% for periodontally involved extracted teeth and 95.8% for teeth extracted for other reasons. Itwas found that bone preservation and less treatment time was the greatest advantage for placing implants in extraction sockets. The maindisadvantage was more complicated tissue handling technique to gain satisfactory esthetics 22.

ConclusionImmediate placement of implant after extraction is a procedure that will become the standard of care in the circumstances outlined.

continued on p. 10


continued from p. 9

Immediate Placement of Implants after Extraction: A Literature Review

Careful use of adjunctive procedures and consideration of the variations in technique will greatly enhance our success using this modality.Recent success can be attributed to the improvements in the texture of implant surfaces and its ability to cause fibrin to stick encouraging

the migration of osteoblasts.The bone growth around HA coated implants is one of its advantages and the current method of plasma spraying as well as the use of

HA below the first few titanium threads have helped to make HA coated implants more desirable for immediate placement.From the entire information available immediate implant placement after extraction is most successful in the anterior maxilla and anterior

mandible after alveoloplasty to remove infected sockets. The presence of vital structures in the posterior maxilla and posterior mandible contraindicatesimmediate placement except under extreme circumstances. Most guidelines recommend preparation of the osteotomy 4mm apical to the apex ofthe tooth socket to achieve primary stability. Presence of boney septums after extractions in these areas serves to deflect osteotomy drills and makeit difficult to obtain proper implant trajectory.

Footnotes and Bibliography1. Int J Oral Surg. 1981 Dec;10(6):387-416. A 15-year study of osseointegratedimplants in the treatment of the edentulous jaw.Adell R, Lekholm U, Rockler B, Branemark PI.2. Int. J Oral Maxillofacial. Implants. 1995 Sep-Oct;10(5):561-7. Immediate anddelayed implantation for complete restoration of the jaw following extractionof all residual teeth: a retrospective study comparing different types of serialimmediate implantation. Watzek G, Haider R, Mensdorff-Pouilly N, Haas R.3. Int J Prosthodont. 1993 Mar-Apr;6(2):169-75. Immediate implants: their currentstatus. Barzilay I.4. J Periodontol. 2004 Jul;75(7):982-8. Immediate implants supporting singlecrown restoration: a 4-year prospective study. Covani U, Crespi R, Cornelini R,Barone A.5. Pract Proced Aesthet Dent. 2004 Jan-Feb;16(1):35-43. Immediate implant place-ment and provisionalization using implants with an internal connection. CastellonP, Block MS, Smith M, Finger IM.6. World Dentistry. 2000 1(1) Immediate Implant Placement in the External RootResorption Case, David A. Garber, DMD, Maurice A. Salama, DMD Henry Salama,DMD7. International Journal of Oral & Maxillofacial Implants; 1998 May/June 13(3):333-341, Implants Placed in Immediate Extraction Sites: A Report of Histologicand Histometric Analyses of Human Biopsies. Thomas G. Wilson, Jr, DDS,Robert Schenk, MD, Prof Dr Med, Daniel Buser, DMD, Prof Dr Med Dent,David Cochran, DDS, PhD, MS, MMSci8. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):843-52. Clinical coverage ofdehiscence defects in immediate implant procedures: three surgical modalitiesto achieve primary soft tissue closure. Nemcovsky CE, Moses O, Artzi Z, Gelernter.9. J Periodontol. 1994 Sep;65(9):881-91. Bone grafting and guided bone regenera-tion for immediate dental implants in humans. Gher ME, Quintero G, Assad D,Monaco E, Richardson AC.10. Practical Periodontics and Aesthetic Dentistry. 3(5):33-40 Immediate Implan-tation After Extraction of a Horizontally Fractured Lateral IncisorKrauser J, Boner C, Boner N.11. Periodontal Insights 6:7-11, 1999. Immediate Placement of a Dental Implantin an Extraction Socket Following Tooth Fracture.Cohen R. E. and Shenoy L.12. Int J Oral Maxillofacial Impl 1997; 12(4):454-462. One-step surgical placementof Brânemark implants: A prospective multicenter clinical study.Becker W, Becker BE, Israelson H, et al.13. Compend Contin Educ Dent. 1997 Sep;18(9):940-2, 944, 946 passim.A 7-year retrospective study of 423 immediate implants. Cosci F, Cosci B.14. Implant Society 1991 2(1):1-3 Immediate Placement of Dental Implants AfterExtraction. Mark L. Mason DMD.15. Int J Periodontics Restorative Dent. 1992;12(3):206-17. The immediate im-plant: bone preservation and bone regeneration. Werbitt MJ, Goldberg PV.16. Int J Oral Maxillofacial Implants. 1990 Winter;5(4):337-45. Immediate fixtureplacement: a treatment planning alternative. Parel SM, Triplett RG.17. Int J Oral Maxillofacial Implants. 1991 Spring;6(1):19-23. The immediate im-plant: a treatment alternative. Krump JL, Barnett BG.18. Int J Periodontics Restorative Dent. 1997 Apr;17(2):140-9. Socket seal surgerycombined with immediate implant placement: a novel approach for single-tooth replacement. Landsberg CJ.19. Int J Oral Maxillofacial Implants. 1995 Nov-Dec;10(6):736-43. Direct replace-ment of failed CP titanium implants with larger-diameter, HA-coated Ti-6Al-4V

implants: report of five cases. Evian CI, Cutler SA.20. Int J Oral Maxillofacial Implants. 1991 Spring;6(1):24-8. Endosseous implantplacement immediately following dental extraction and alveoloplasty: prelimi-nary report with 6-year follow-up. Tolman DE, Keller EE.21. Int J Oral Maxillofacial Implants. 1999 Mar-Apr;14(2):210-6. A 3-year prospec-tive multicenter follow-up report on the immediate and delayed-immediateplacement of implants. Grunder U, Polizzi G, Goene R, Hatano N, Henry P,Jackson WJ, Kawamura K, Kohler S, Renouard F, Rosenberg R, Triplett G,Werbitt M, Lithner B.22. Int J Oral Maxillofacial Implants. 1996 Mar-Apr;11(2):205-9. Immediate place-ment of implants into extraction sockets: implant survival. Rosenquist B, Grenthe.

Dr. Bertrand A. A. Bonnick D.D.S, F.A.G.D. maintains a gen-eral practice in Geensboro, NC with an emphasis on implants,cosmetic dentistry and laser treatment. He has been an instructorin national institutional and continuing education programs. Hecan be reached at [email protected].

Dr. Andrew Kelly maintains a private practice in North Carolina,is a graduate of the Core Vent Institute in Encino, California andThe Implant Maxi Course at the Medical College of Georgia andhas been placing and restoring implants since 1988. Dr. Kelly is anactive member The Academy of General Dentistry, The AmericanAcademy of Implant Dentistry, and International Congress ofOral Implantology. He has served as a Deputy Examiner for theNorth Carolina Sate Board of Dental Examiners. He can be reachedat 336-766-7966 or [email protected].

Richard Ngyuen maintains a private practice in Houston, TXand has completed a post-doctoral program in Advanced Educa-tion in General Dentistry.

Dr. Jean Woods maintains a general practice in Chapel Hill, NC.She is a certified implantologist after completing the AmericanAcademy of Implant Dentistry Maxi Course at the Medical Col-lege of Georgia. . Dr. Woods maintains active membership in RoyHeash Study Club, Academy of General Dentistry, American Acad-emy of Implant Dentistry, and the National Dental Association.She has served as deputy examiner for the NC State Board ofDental Examiners.

Alex Resnansky, DDS maintains a general practice in Raleigh,North Carolina with an emphasis on Cosmetic Dentistry, Im-plant Dentistry, and Tissue Regeneration procedures. He taughtbriefly in the Department of Restorative Dentistry SUNY at StonyBrook School of Dental Medicine. He can be reached [email protected].


Are Dental Implants a Predictable Alternative?continued from p. 5

References1 United Network for Organ Sharing. 30 November 2004. Online. Internet.30 November 2004. Available http://unos.org/2 Silvestri, Pam. “Projection for waiting list.” E-mail to Cheryl Thomas,RDH. 18 November 2004.3 Lo NN, Tan JS, Tan SK, Vathsala A. “Results of total hip replacement inrenal transplant recipients.” Ann Acad Med Singapore. 1992 Sept;21(5):694- 8.4 Deo S, Gibbons CL, Emerton M, Simpson AH. “Total Hip Replacementin Renal Transplant Patients.” Bone Joint Surg. Br. 1995 Mar; 77(2):299-3025 “Antibiotic Prophylaxis for Dental Patients with Total Joint Replace-ments.” 2002. Online posting. http://www.aaos.org/wordhtml/papers/advistmt/1014.htm. Internet. 30 November 2004.6 National Kidney Foundation Fact Sheets. 2004. Online. 3 November2004. Internet. Available http://www.kidney.org/general/news/factsheet.cfm?id=5

Cheryl Thomas, RDH is experienced in general dentistry, pediat-ric dentistry, and public health. In 1997, she was diagnosed withend stage renal disease due to ANCA+ Vasculitis. She received arenal transplant in 1999 with her brother as the donor. She foundeddentalInspirations, Inc. in 2002. Cheryl teaches continuing educa-tion to dental professionals regarding the dental management oforgan transplant recipients. In addition, Cheryl is a volunteerspeaker for the Southwest Transplant Alliance and a member ofthe Speaking Consulting Network and Toastmasters. She can bereached at 409-744-5855 or [email protected] Hollister Slim, RDH, BSDH, MSDH is President ofPerio C Dent (Perio-Centered Dentistry), a practice managementconsulting firm that specializes in creating outstanding dental hy-giene teams. Lynne has published in Dental Economics, RDHmagazine, Access magazine and the Journal of Dental Hygiene onnon-surgical periodontal therapy and other topics of interest tothe general dentist/hygienist team including coaching dysfunc-tional teams. Lynne is a member of the Speaking and ConsultingNetwork (SCN) and is owner/moderator of a periodontal thera-pist yahoo group: http://yahoogroups.com/group/periotherapist. She can be reached at [email protected] C. Wadsworth, RDH has a consulting business in NewHope, PA and specializes in dental hygiene department growth,implementation of protocols for case management, and custom-ized communications workshops and lectures for dentists andteam members. Lisa has also worked as a Registered Dental Assis-tant and Certified Implant assistant. Lisa is a member of theSpeaking/Consulting Network and can be reached at 215.862.5912or [email protected].

15 Novacek, G. et al. “Dental and periodontal disease in patients withcirrhosis – role of etiology of liver disease.” Journal of Hepatology Volume 22(1995) 576-582.

10 Novartis Transplant. 2002. Novartis Pharmaceuticals Corporation.Internet. 30 November 2004.11 Simpkins, Brian, Schonder, Kristine. ”Sticks and Stones (and TransplantMedications) May Break My Bones.” iKidney.com. August 2004. Online.Internet. 30 November 2004. Available http://www.ikidney.com/iKidney/Lifestyles/SticksandStonesMayBreakMyBones.htm12 Ogbru, Omudhome, Pharm. D. Medicinenet.com. 12 March 2002.Online. Internet. 30 November 2004. Available http://www.medicinenet.com/prednisone/article.htm13 Lindberg, Jill S. , MD, Moe, Sharon M., MD, Stehman-Breen, CatherineMD, MS. “Managing Osteoporosis/Renal Disease.” iKidney.com. 2000.Online. Internet. 30 November 2004. Available http://www.ikidney.com/i K i d n e y / I n f o C e n t e r / N e p h r o l o g y I n c i t e / A r c h i v e /ManagingOsteoporosisRenalOsteodystrophy.htm.14 “Have Researchers Found a Possible Cure For Renal Bone Disease?”iKidney.com Newsletter, The Journal of the American Society of Nephrology. April 2004. Online. Internet. 30 November 2004. Available http://www.ikidney.com/ikidney/infocenter/nephrologyincite/archive/currentinsight13.htm

7 Heckmann, Siegfried Martin, et al. “Implant Therapy Following LiverTransplantation: Clinical and Microbiological Results After 10 Years.” JPeriodontal Volume 75 (June 2004):75:090-913.8 Heckmann, Siegfried Martin. “Dental Implant Therapy for Organ Trans-plant Recipients.” E-mail to Cheryl Thomas, RDH. 8 November 2004.9 Gaston, Robert S. “Medical Complications of Renal Transplantation.”Transplantation as Treatment of End-Stage Renal Disease. Online. Internet.30 November 2004.http://www.kidneyatlas.org/book5/adk5-13.ccc.QXD.pdf

The article will be continued in the May/June 2005

issue of Implant News & Views Implant News & Views Implant News & Views Implant News & Views Implant News & Views and will discuss

dental implant treatment with HIV -AIDS patients.

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